NABH Standards For Accreditation Of Healthy · PDF file3 National Accreditation Board for...

1

National Accreditation Board for Hospitals & Healthcare Providers1

Sensitization SessionFor IMA

Dr. Arati Verma

Member, Technical Committee, NABH

NABH Standards For Accreditation Of

Clinics


Wish you

a Very Happy,

Healthy

and

Prosperous

New Year.


Setting the Context“National Initiatives: Quality Healthcare for all”

HealthcareInfrastructure


The quest for Quality is all pervasive in this day and age, and never more apparent than in Healthcare

Healthcare Organizations all over the world are increasinglyrecognizing the need to evaluate and demonstrate the quality

of what they do

Different Countries are making different choices about which processes best suit their needs

Newer Models and Innovations are driving Improvements


Drivers

Rising Consumer

Expectations

Consumer Protection

Act

Competition Insurance

Regulation


Quality Building Blocks

Availability of Beds, OPDs, Availability of Beds, OPDs,

Staff, Building, SpaceStaff, Building, Space

Equipment, Supplies, Equipment, Supplies,

Resources, Basic Monitoring of Resources, Basic Monitoring of

patientspatients

Protocols, Procedures,

Treatments, Policies, Training,

Efficiency, low waste,

Appropriate use

Patient & staff satisfaction,

Low infection rates, good

clinical outcomes

Structures

(Good foundation

is critical)

Outcomes

Processes

2


National Accreditation Board for Hospitals

and Healthcare Providers (NABH)

The National leader in raising the

bar for healthcare QualityAnd Safety


Specifically address:

• Patient Rights

• Access and Care of patients

• Infection Control• Patient Safety

• Continuous Improvement

The Indian National

Standards (NABH) have been

benchmarked with international Accreditation

standards (USA, UK, Australia):

Hospitals

Small HCOs

Blood Banks

NABL for Pathology Services

Community Health Centers

Imaging

Clinics

Dental Centers

NABH: National Accreditation Board for Hospitals and Healthcare Organizations

Recently Launched-Wellness Centre Standards


MIMS Hospital

Fortis

Mohali,

Max

Super Speciality

Hospital

Columbia Asia

Medical Centre

Baby

Memorial

Hospital

Fortis

Hospital,

Noida

Dr. L. H.

Hiranandani

Hospital

Max Devki Devi

Heart & Vascular

Institute

B.M. Birla

Heart Research

Centre

Moolchand

Hospital

Narayana

Hrudayalaya

NABH Accredited Hospitals

Nethradhama

Superspeciality

Eye Hospital

Sagar HospitalsManipal

Hospital

Lakeshore

Hospital

& Research

Centre Ltd

Escorts

Heart Institute

And

Research Centre

Sir Ganga

Ram

Hospital

Fortis

Escorts

Hospital Medwin

Hospitals

Sevenhills

Hospitals Ltd

Dharamshila

Hospital &

Research Centre

Chacha

Nehru Bal

Chikitsalaya

Kailash

Hospital &

Heart Institute

G. Kuppuswamy

Naidu

Memorial

Hospital

Amrita

Institute

Of Medical

Sciences

Sterling

Hospitals

Apollo

Speciality

Hospitals

Paras

Hospitals

Wockhardt

Hospital

P.D. Hinduja Godrej

Memorial

50 +Accredited hospitals

Over 300 Applicants

Both Government & Private Hospitals are going for NABH


Government Healthcare is rapidly gaining

awareness and participation

� QCI is running QA programs in the following states:� Delhi: 9 hospitals (1 already fully accredited)

� Gujarat: 32 hospitals ( 2 already accredited) � Kerala: 19 hospitals (5 have applied for pre

assessment)� Tamil Nadu: 12 (all have undergone pre assessment)� Andhra Pradesh: 3� UP: 1 fully accredited

� MP: 5 Lab, Blood BanksPHC and CHC also included

in many states Talks ongoing to commission projects in many other states (Haryana, Orissa, J&K etc)


Impact of NABH Accreditation on a Government Hospital

1650

1236

950

15

200

510

1300

10110

484

0

200

400

600

800

1000

1200

1400

1600

1800

Noof beds Average Daily Aver Daily IPD

OPD

Average Daily

deliveries

Average Lab

investigations

2006-07 2007-08

5%

increase

27%

increase 30%

increase

82%

increase50%

increase

Source: Quality Assurance Program (NABH Accreditation in Gujarat)

Average daily IPD increased by 100% Average daily OPD increased by 27%

Bed Occupancy ratio increased from 77% to 89%, ALOS decreased by 25%


Impact of accreditation in Govt Hospital

2.4

3.2

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

2006-07 2007-08

Dept of Health and Family Welfare, Government of Gujarat

Average length of Stay

3


NABH hospital standards, 2nd edition,

November 2007:

� Accredited by The International Society for

Quality in Healthcare (ISQua)

International

Recognition for National

Standards


NABH Accreditation involves:

� Assessment and peer evaluation focused

on performance measurement and

management, risk prevention, staff and patient

safety, quality improvement, and governance.

COLLABORATIONPARTNERSHIP

MUTUAL LEARNING


NABH Accreditation

� One of the most effective ways for health

care organizations to:

�assess and improve the quality and safety of

their services

�demonstrate that they meet or exceed national standards of excellence


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NABH Accreditation supports…NABH Accreditation supports…

� Quality improvement

� Patient safety

� Risk management

� Change management


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NABH StandardsOrganized around important functions

� Can be applied to any clinic

� Focus on patient and staff safety

� Set standards that all organizations must pass

� To be revised periodically and raise the “bar”

� Achieve external recognition

� Improve patient outcomes


S.

no.

Healthcare

facility

Definition

1. Clinic A standalone healthcare facility for services

(other than OPD of a hospital).

2. Polyclinic A Clinic which provides services in 2 or

more specialties, working in cooperation and

sharing the same facilities

3. Dispensary A Clinic, which in addition to patient care,

provides facilities for dispensing medicines. .

DEFINITION OF CLINIC:

A standalone healthcare facility that provides allopathic services by Doctors registered with Medical Council of India or State Medical Council.

The Clinic may be located in the community or in the premises of an organization, such as school, factory, etc., and includes the following types of healthcare facilities:

4


In addition a “clinic” may have add on services as follows:

Diagnostic services such as:

•Laboratory

•Imaging

•Other

Therapeutic services such as:

•Procedures

Support services such as:

•Pharmacy

•Physiotherapy•Nutrition

•Counselling etc.

National Accreditation Board for Hospitals & Healthcare Providers

S. No Chapter Standards Objective

Elements

1 Access, Assessment & Continuity

of Care(AAC)

7 33

2 Care of Patients (COP) 6 27

3 Patient Rights and Education(PRE) 5 26

4 Infection Control (IC) 2 8

5 Continuous Quality Improvement

(CQI)

2 8

6 Responsibilities of Management

(ROM)

4 20

7 Facilities Management and

Safety(FMS)

3 12

8 Community Participation and

Integration

1 5

Total 30 139

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NABH Standards For Accreditation of Clinics


CHAPTER 1: Access,

Assessment and Continuity of Care (AAC)


AAC.1. The Clinic defines and displays the services that it can

provide.

a) The services provided are clearly defined and are in

consonance with the needs of the community it intends to

serve, and its mission, resources and scope of services.

b) Clinic identifies barriers to access and implements processes

to reduce those barriers that have potential to limit access to

the Clinic and its services.

c) The services provided are displayed.

Access, Assessment and Continuity of Care (AAC)



AAC.2. The Clinic has a well defined patient registration

process and appropriate mechanism for referral of

patients who do not match the Clinic’s resources.

a) Standardized policies and procedures are used for

registering patients.

b) Patients are registered only if their needs match the

clinics mission and resources.

c) If the patients needs do not match the clinics mission

and resources, the clinic will assist the patient in

identifying and/or obtaining appropriate sources of

care.



AAC.3. Patient’s initial and continuing healthcare needs are identified through an

established assessment process.

a) The Clinic defines the scope and content of initial assessment conducted by

different specialities / providers / disciplines based on applicable laws and

regulations.

b) The Clinic defines criteria when additional, specialized, or more in depth

special needs assessments are required for some patients.

c) Initial assessment may use screening criteria or other mechanisms to identify

patients who may need additional care.

d) The Clinic has a policy and procedure which defines the process for how the

outside assessments are incorporated into the assessment process.

e) There is an established process for meeting patient care needs requiring

continuing care.

f) The assessment findings result in a documented plan of care.

g) The plan of care also includes preventive aspects of the care as applicable.

5



AAC 4: The Clinic has a process to identify those patients who may need

additional care that is beyond the scope and mission of the Clinic and

advises those patients to seek additional care , treatment or follow-up

a) Policies and procedures are used to identify the additional care needs of

the patients and to appropriately refer them to outside healthcare providers

b) Written summaries are provided to the patients and referring provider

c) The Clinic attempts to facilitate and coordinate sharing of information and

plans of care between referral agencies to ensure proper coordination of

care between multiple providers, if applicable.



AAC 5: The Clinic has a process to identify the transportation

needs of the patients and facilitate the same as

applicable.

a) Policies and procedures address identification of

transportation needs of the patient and their facilitation

b) Ambulance or patient transport services, if provided, are

organised through defined policies and procedures for

efficient and effective services

c) Ambulance or patient transport services, if provided, comply

with the legal and regulatory requirements.



AAC.6. Laboratory services if provided, are as per the mission and

scope of the Clinic.

a) Lab services, if provided, on site are commensurate with the scope of

services and comply with applicable local and national standards, law and

regulations.

b) Lab services if provided on site will have a quality control and laboratory

safety programme.

c) Adequately qualified and trained personnel perform and/or supervise the

investigations.

d) Policies and procedures guide collection, identification, handling, safe

transportation, processing and disposal of specimens.

e) Laboratory results are available within a defined time frame.

f) Critical results are intimated immediately to the concerned personnel.

g) Laboratory tests not available in the Clinic are outsourced or referred to

outside sources to meet patient needs.



AAC.7. Imaging services if provided are as per the mission and

scope of the Clinic.

a) Imaging services if provided are as per applicable local and national

standards, law and regulations

b) Imaging services if provided on site will have a quality control and

Radiation safety programme

c) Adequately qualified and trained personnel perform and/or supervise the

imaging.

d) Policies and procedures guide the handling and disposal of radio-active

and hazardous materials.

e) Imaging results are available within a defined time frame.

f) Critical results are intimated immediately to the concerned personnel.

g) Imaging services if not available in the Clinic are outsourced or referred to

outside resources to meet patient needs.


CHAPTER 2: Care of Patients (COP)


CHAPTER 2 : Care of Patients (COP)

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COP.1 Care and treatment is provided in a uniform manner to

ensure high level of patient care.

a) Policies and procedures guide the uniform level of care for all

patients, which reflect applicable laws and regulations.

b) Care of patients should be in consonance with the defined

scope

c) Evidence based medicine and Clinical practice guidelines are

adopted to guide patient care wherever possible.

6


Care of Patients (COP)

31

COP 2 Policies and procedures guide the care & treatment of

patients with special identified needsa) Policies and procedures guide the provision of services to the high-risk patients.

b) Policies and procedures guide the provision of services that are associated with

risk in the clinic setting.

c) Policies and procedure guide basic and first responder emergency care.

d) Policies address handling of medico-legal cases.

e) Policies and procedures guide the care & treatment of vulnerable patients and are

in accordance with the prevailing laws and the national and international

guidelines.

f) Policies and procedures guide the care of patients undergoing procedures.

g) Policies and procedures guide the provision of rehabilitative services and

commensurate with the clinical requirements, as applicable.

h) Policies and procedures guide the management of pain.

i) Policies and procedures guide the care of patients undergoing moderate sedation.



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COP 3: Medication use is organized to meet patient needs and

complies with applicable laws and regulations

a) Policies and procedures guide how the Clinic will meet

medication needs of the patient.

b) The medication use meets applicable laws & regulations.

c) Antibiotic prescription is guided by evidence based

guidelines.

d) The medications available are appropriate to the Clinic’s

mission, scope of services and patient needs.

e) Policies and procedures guide the procurement process,

storage labelling and management of medications.



33

COP.4. Medication prescription, dispensing and administration

follow standardized processes to ensure patient safety.

a) Medications are prescribed, dispensed and administered by

authorized persons.

b) Medications are prescribed in a clear legible manner, dated

and timed.

c) In case medications are dispensed at the Clinic,

standardized policies and procedures are used for safe

dispensing.

d) Medication administration is guided by standardized policies

and procedures.



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COP.5 Medication use is monitored for patient compliance, clinical

appropriateness and adverse effects and the medication errors are

appropriately addressed.

a) Medication use is monitored for patient compliance, clinical effectiveness

and adverse medication effects; and the same is noted in patient’s record.

b) Adverse medication effects are defined, analyzed, documented and

reported to the collaborating centre as applicable.

c) Patients and family members are educated about safe and effective use

of medication and food-drug interactions.

d) Policies and procedures defines reporting mechanism, analysis and

implementation of corrective and preventive actions for medication error

and adverse drug events.



35

COP.6. Policies and procedures guide all research

activities.

a) Policies and procedures guide all research activities in

compliance with the applicable law and national and

international guidelines.

b) Policies and procedures address Patient’s informed

consent, their right to withdraw, and their refusal to

participate in the research activities.



36

COP.1 Care and treatment is provided in a uniform manner to

ensure high level of patient care.

a) Policies and procedures guide the uniform level of care for all

patients, which reflect applicable laws and regulations.

b) Care of patients should be in consonance with the defined

scope

c) Evidence based medicine and Clinical practice guidelines are

adopted to guide patient care wherever possible.

7


CHAPTER 3: Patient Rights and Education

(PRE)


Patient Rights and Education (PRE)

38

PRE.1 The Clinic protects patient and family rights and informs

them about their responsibilities during care.

a) Patient and family rights and responsibilities are documented.

b) Patients and families are informed of their rights and

responsibilities in a format and language that they can

understand.

c) The Clinic’s leaders protect patient’s rights.

d) Staff is aware of their responsibility in protecting patient’s

rights.

e) Violation of patient rights is reviewed and

corrective/preventive measures are taken.



39

PRE.2 Patient rights support individual beliefs, values and involve the patient and

family in decision making processes.

a) Patient and family rights address any special preferences, religious and cultural

needs.

b) Patient rights include respect for personal dignity and privacy during examination,

procedures and treatment.

c) Patient rights include protection from physical abuse or neglect.

d) Patient rights include treating patient information as confidential.

e) Patient has the right to make an informed choice including the option of refusal.

f) Patient rights include informed consent for any invasive / high risk procedures /

treatment.

g) Patient rights include information and consent before any research protocol is

initiated.

h) Patient rights include information on how to voice a complaint.

i) Patient has a right to have an access to his / her Clinical records.



40

PRE.3 A documented process for obtaining patient and / or

families consent exists for informed decision making

about their care.

a) The Clinic has listed those procedures and treatment

where informed consent is required.

b) Informed consent includes information on risks, benefits,

alternatives and as to who will perform the requisite

procedure in a language that they can understand.

c) The policy describes who can give consent when patient is

incapable of independent decision making.



41

PRE.4 Patient and families have a right to information and

education about their healthcare needs.

a) When appropriate, patient and families are educated about the

safe and effective use of medication and the potential side

effects of the medication.

b) Patient and families are educated about diet and nutrition.

c) Patient and families are educated about immunizations.

d) Patient and families are educated about their specific disease

process, prognosis, complications and prevention strategies.

e) Patient and families are educated about preventing infections.



42

PRE.5 Patient and families have a right to information on

expected costs.

a) The tariff list is available to patients.

b) Patients are educated about the estimated costs of treatment.

c) Billing, receipts and records are maintained as per statutory

requirements.

d) Patients are informed about the estimated costs when there is

a change in the patient condition or treatment setting.

8


CHAPTER 4: Infection Control

(IC)


Infection Control (IC)

IC.1. The Clinic has a well-designed, comprehensive and

coordinated Infection Control programme aimed at reducing

/ eliminating risks to patients, visitors and providers of care.

a) The Clinic has documented policies and procedures for infection control

as applicable to its scope.

b) It focuses on adherence to standard precautions at all times.

c) Cleaning, Disinfection of surfaces, equipment cleaning and sterilization

practices are included.

d) Laundry and linen management processes are also included.

e) Staff in Clinic receive regular training in infection control practices

f) Occupational risks are known to staff and they are trained to prevent

these; and to take corrective and preventive actions in case of exposure.


Infection Control (IC)

IC.2. The Clinic complies with Bio Medical Waste

regulations as applicable

a) Bio Medical waste is collected, handled, segregated

and disposed of as per the regulations

b) Staff is trained to handle BMW, and follow

precautions


CHAPTER 5: Continuous Quality Improvement (CQI)


Continuous Quality Improvement (CQI)

CQI.1 There is a structured quality improvement and

continuous monitoring programme.a) The quality improvement programme is commensurate with the size and

complexity of the clinic and is documented.

b) The quality improvement programme is comprehensive and covers all the

major elements related to quality improvement and risk management.

c) The activities to achieve conformance with the defined quality

management programme are communicated and coordinated amongst all

the employees of the Clinic through proper training mechanism.

d) The quality improvement programme is reviewed at predefined intervals

and opportunities for improvement are identified.


Continuous Quality Improvement (CQI)

CQI.2. The clinic identifies key indicators to monitor the Clinical and

managerial structures, processes and outcomes which are

used as tools for continual improvement

a) The clinic develops appropriate key performance indicators

suitable to monitor clinical structures, processes and outcomes.

b) The clinic develops appropriate key performance indicators

suitable to monitor managerial structures, processes and

outcomes

c) There is documentation of monitoring activity.

d) Corrective and preventive actions are taken and monitored for

effectiveness with respect to activities being managed or

monitored.

9


CHAPTER 6: Responsibilities of

Management (ROM)


Responsibilities of Management (ROM)

ROM.1 The responsibilities of the management are defined.

a) Those responsible for governance lay down the clinic’s

mission statement, budget and resources

b) Those responsible for governance establish the Clinic’s

organogram, as applicable.

c) Administrative policies and procedures for each section

are maintained.

d) The organisation complies with the laid down and

applicable legislations and regulations.

e) Those responsible for governance address the

organisation’s social responsibility.



ROM.2. The Clinic is managed by the leaders in an ethical manner.

a) The Clinic functions in an ethical manner.

b) The Clinic discloses its ownership.

c) The Clinic honestly portrays its affiliations and accreditation.

d) The Clinic accurately bills for its services based upon a standard

billing tariff.

ROM 3 The Clinic initiates and maintains a patient record for every

patient.

a) Only authorized persons make entries in the patient record.

b) Every patient record has a unique identifier and the record contains

sufficient information to meet patient care needs and regulatory

requirements.

c) The retention period and storage requirements are defined and

implemented.

d) Standardized forms and formats are used.



ROM 4: Those responsible for management have addressed all

applicable aspects of human resource management.

a) The Clinic maintains an adequate number and mix of staff to meet the

care, treatment and service needs of the patient.

b) The required job specifications and job description are well defined for

each category of staff.

c) The Clinic verifies the antecedents of the potential employee with

regards to credentials, criminal/negligence background, training,

education and skills.

d) Each staff member, employee and voluntary worker is appropriately

oriented to the mission of the Clinic, policies and procedures as well as

relevant department / unit / service/ programme’s policies and

procedures.

e) The Clinic staff participates in continuing professional education

programs.

f) Performance evaluation systems are in place, as applicable.

g) Staff Health Problems are addressed.


CHAPTER 7: Facility Management and

Safety


Facility Management & Safety(FMS)

FMS.1 The Clinic’s environment and facilities operate to

ensure safety of patients, their families, staff and

visitors.

a) Up-to-date drawings are maintained which detail the site

layout, floor plans and fire escape routes.

b) There is internal and external sign posting in the Clinic in

a language understood by patient, families and

community.

c) The provision of space shall be in accordance with the

available literature on good practices (Indian or

International Standards)

10



FMS.2 The Clinic has a programme for equipment management,

safe water, electricity, medical gases and vacuum system

as applicable.

a) The Clinic plans for equipment in accordance with its services

and strategic plan.

b) Potable water and electricity are available.

c) Alternate sources are provided for in case of failure.

d) The organisation regularly tests the alternate sources.

e) Safety precautions are followed with respect to medical gases

and where applicable piped medical gas, compressed air &

vacuum installation/equipment.



FMS.3 The Clinic has plans for emergencies (fire and non-

fire) and hazardous materials within the facilities.

a) The Clinic has plans and provisions for early detection,

abatement and containment of fire and non-fire emergences.

b) Staff is trained for their role in case of such emergencies.

c) The Clinic has addressed identification, spill management,

training of staff storage and disposal of Hazardous materials.

d) The Clinic defines and implements its policies to reduce or

eliminate smoking.


CHAPTER 8: Community

Participation &

Integration (CPI)


Community Participation & Integration (CPI)

58

CPI.1. The commitment of the Clinic to Health promotion and

disease prevention is evident in its mission statement, value

statement, collaborative arrangements with local, regional

and national agencies and relevant policies and community

participation.a) The clinic defines Policies and procedures for health promotion / wellness

and disease prevention / control programs that it participates in, asapplicable.

b) The Clinic keeps abreast and implements national/regional or local

standards and guidelines which are in consonance with its mission andobjectives.

c) Clinic provides education, counselling and information to community

partners and priority population on variety of topics for health promotion,Health protection, and disease prevention and control.

d) Clinic cooperates and collaborates with the community partners in

provision of surveillance, epidemiological investigations, data collection,when required..

e) There is a process in place for reporting notifiable diseases as perprevailing law and regulations.


Small Healthcare Organizations

59


Emphasis

� Admission & Discharge

� Indoor Services

� Emergency

� Continuity of Care

� ICU

� OT

� Transfusion

� Medications

60

� Infection Control

� Hazards

� Documentation

11


We Need Your Commitment…..To make a New Beginning ….

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NABH Standards For Accreditation Of Healthy · PDF file3 National Accreditation Board for...

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